NCP Thromboangiitis Obliterans - Nursing Diagnosis and Interventions

NCP Thromboangiitis Obliterans - Nursing Diagnosis and Interventions

1. Acute Pain / Chronic Pain related to vasospasm / reperfusion disorders, ischemic / tissue damage.
Goal: Pain is reduced and tissue damage is not widespread.
Intervention:

• Record the characteristics of pain and paresthesias.


• Check the patient's vital signs.


• Discuss with the patient, how and why the pain inflicted.


• Help the patient identify trigger factor or situation example: smoking, exposure to cold and how to handle.


• Encourage the use of stress management techniques, entertainment activities.


• Soak the affected area in warm water.


• Give the room a warm, draft-free air, for example ventilation, air-conditioning, keep doors closed as indicated.


• Monitor drug effects and action.


• Collaboration: the medications as indicated, prepare surgical intervention when necessary.

Rational:

• Knowing the pain level.


• To monitor the general state of the client.


• That patients understand how to process pain.


• That patients understand the factors that influence pain.


• Used to divert the attention of the client.


• Warm water will make the blood vessels will dilate and blood flow.


• Avoid infection and keep the air hot.


• Determine the level of effectiveness of the drug.


• Administration of drugs to relieve pain.

2. Ineffective Tissue Perfusion is related to cessation of arterial blood flow
Intervention:

• Observation of skin color on the sick.


• Note the decrease in pulse.


• Evaluation of pain sensation parts, for example: sharp / shallow, hot / cold.


• View and examine the skin for ulceration, lesions, gangrene area.


• Recommended for proper nutrition and vitamins.


• Collaboration: the medications as indicated (vasodilator), example: drainage lesions for culture or sensitivity.

Rational:

• To see cyanosis or redness of the skin.


• Identify the severity of the cessation of arterial blood flow.


• Knowing levels, flavors, and forms of pain.


• Seeing how big a part that had gangrene.


• Proper nutrition and vitamin requirements are complete will increase the body's immune system.


• Giving obta vasodilator make the arteries dilate and blood flow.

3. Knowledge Deficit: the need to learn about the condition, treatment needs related to lack of knowledge / resources are not familiar with, wrong perception / misunderstood.
Intervention:

• Provide information to patients about the disease.


• Encourage clients to ask questions about the disease.


• Instruct to avoid exposure to cold.


• Preserve the environment at a temperature above 20.9 C eliminate cold flow.


• Discuss the possibility of moving to a warmer climate.


• Emphasize the importance of stopping smoking, provide information on local clinics / support group.


• Help the patient to create a method to avoid or alter discuss stress relaxation techniques.


• Emphasize the importance of viewing each day and do the right skin care.

Rational:

• Increase patients' knowledge about the disease.


• Knowing the client's level of curiosity about the disease.


• Cold temperatures make the constriction of the blood vessels and will aggravate the blockage of blood flow.


• Hot temperature makes blood vessels to maintain a state of dilatation.


• Avoid the severity of which will happen.


• That patients know and understand that smoking is a major contributing factor to the occurrence trombongitis.


• Distraction and relaxation techniques to make the patient more calm in responding.


• Avoid skin injury.

4. Anxiety related to the action procedure to be performed
Intervention:

• Describe the action procedure to be performed.


• Explain the importance of actions to be taken.


• Observation of vital signs.


• Give comfort to the patient.


• Reassure the patient that the action to be performed is the best course of action.


• Reassure the patient that the procedure acts to be performed safely.


• Collaboration with physicians for the provision of drugs.

Rational:

• Increase patients' knowledge about action procedure.


• In order for patients to understand why the need for that action.


• Knowing the general state of the client.


• Patients will feel calm and do not worry with action procedures to be performed.


• Reduce the level of anxiety on the client.


• Reduce negarif thinking about an act procedures.


• To create a calm and reduce anxiety levels.

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